The nurse is assessing the apical pulse. Where should the stethoscope be placed?

Between the fourth and fifth intercostal space.

Between the third and fourth intercostal space.

Between the second and third intercostal space.

Between the first and second intercostal space.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The apical pulse is located at the fifth intercostal space at the left midclavicular line.

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Correct Answer is D

Explanation

Choice A rationale
Enlargement of the liver is not a common complication following a myocardial infarction that has caused damage to the right side of the heart.
Choice B rationale
Pulmonary congestion is more commonly associated with left-sided heart failure.
Choice C rationale
Cardiac Tamponade is a serious medical condition in which blood or fluids fill the space between the sac that encases the heart and the heart muscle. This can occur as a result of a myocardial infarction, but it is not the most likely complication in this scenario.
Choice D rationale
Peripheral edema is a common complication following a myocardial infarction that has caused damage to the right side of the heart. When the right side of the heart is damaged, it can lead to a backup of blood in the body’s veins, which can cause swelling in the ankles, legs, and abdomen.

A. Quality and Safety Education for Nurses (QSEN). B. Institute of Medicine (IOM). C. Centers for Disease Control (CDC). D. Health Insurance Portability and Accountability Act (HIPAA).

Correct Answer is A

Explanation

Choice A rationale
The Quality and Safety Education for Nurses (QSEN) project provides a roadmap to transform nursing by integrating six competencies: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
Choice B rationale
The Institute of Medicine (IOM) is a non-profit organization that provides unbiased and authoritative advice to decision makers and the public. While the IOM has made significant contributions to health care, it does not specifically develop safety competencies for nurses.
Choice C rationale
The Centers for Disease Control (CDC) is a national public health institute in the United States. It conducts and supports health promotion, prevention and preparedness activities in the United States, with the goal of improving overall public health.
Choice D rationale
The Health Insurance Portability and Accountability Act (HIPAA) is legislation that provides data privacy and security provisions for safeguarding medical information. While HIPAA contributes to the safety and privacy of patient information, it does not develop safety competencies for nurses.

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The nurse is assessing the apical pulse. Where should the stethoscope be placed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

Explanation

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